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Based on a review of facility documents, patient records, facility policies, and staff interviews, the governing body failed to ensure that services were rendered in a safe and effective manner as evidenced by:

1. Failing to ensure that the Quality Assurance and Performance Improvement program implemented and monitored action plans related to an adverse patient event (death) to ensure the safety of patients at the facility and prevent future occurrences. Cross refer to A0263 and A0309.

2. Failing to ensure facility based policies and procedures were implemented and enforced. Cross refer to A0386.

Based on a review of records, policy, and interviews, it was determined that the hospital's governing body failed to ensure that the quality assessment and performance improvement program focused on the prevention and reduction of medical errors. It was determined that the facility:

1. Failed to ensure that patient safety was maintained, due to the fact preventative actions identified post an adverse event were not effectively implemented and monitored. Cross refer to A0286 and A0309.

Based on a review of records, documentation, and interview, it was determined that the facility failed to ensure that performance improvement activities related to an adverse patient event, implemented identified preventive actions and mechanisms that included feedback and learning throughout the hospital. The facility governing body also failed to ensure that clear expectations for safety were established and implemented.

Findings were:

Patient #1 was transferred from a nursing home to the facility emergency room on 09/27/13. The patient was ventilator dependent, with a tracheostomy. The fact the patient was ventilator dependent was not noted by the facility. The patient was not placed on a ventilator and expired at 3:15 AM on 09/28/13.

The facility completed a Root Cause Analysis (RCA) related to this adverse event on 10/01/13 with a follow up meeting on 10/14/13. The RCA identified several action plans to prevent similar incidents in future. The action plans included the development of a "Nursing Home Transfer" form that include an area to note if the patient is on a ventilator and "if yes current vent settings or O2 requirements", use of this form was to be implemented within 2 weeks of the RCA completion. Other actions plans included: training Emergency Department staff on use of the form and auditing 10 cases per week to evaluate effectiveness of implementing the form.

The facility also identified that the Medical Executive Committee (MEC) was to address physicians working or receiving report on patients sent to the Emergency Department, need to contact the designated ED physician and provide "appropriate information to facilitate safe care and admission information". This was to be addressed at the MEC meeting on 11/12/13.

Review of facility provided documentation revealed the above facility identified actions had not been effectively implemented or monitored by the facility.

Facility provided meeting minutes revealed the following:
The Quality Review Committee Minutes for 11/05/13, revealed that the issue of physician to physician communication in the Emergency Department was discussed. "QRC recommended forwarding this issue to MEC for discussion and dissemination to the departments and sections."
The Medical Executive Committee Minutes for 11/12/2013 revealed no discussion of physician to physician communication in the Emergency Department, per facility based action plan.

In an interview on 12/04/13, staff member # 4 confirmed that there was no documentation of audits (10 cases per week) of the "Nursing Home Transfer" form. Staff member #4 indicated that the auditing was accomplished by randomly performing charts checks of patients transferred from nursing homes to see if the forms were being used by ambulance and ED staff. Staff member #4 stated they had only observed the use of, "maybe 2 forms since I started checking".

Review of records for 16 patients transferred from a nursing home to the facility emergency department (dates of 11/10/13 through 11/14/13) revealed that only 6 "Nursing Home Transfer" Documents had been completed. This indicated the "Nursing Home Transfer" form was not being utilized and implemented consistently in the facility since its creation.

Due to the facility's failure to ensure that the proposed action plans were appropriately implemented and monitored, there remains a risk for a similar adverse event to occur, compromising the safety of patients in the facility.

The above findings were confirmed in an interview on 12/04/13 with staff members #1 and 4.

Based on a review of records, documentation, and interview, it was determined that the facility governing body failed to ensure that performance improvement activities related to an adverse patient event, implemented identified preventive actions and mechanisms that included feedback and learning throughout the hospital. The facility governing body also failed to maintain accountability for implementation of the quality improvement program.

Findings were:

The facility completed a Root Cause Analysis (RCA) related to this an adverse event on 10/01/13 with a follow up meeting on 10/14/13. The RCA identified several action plans to prevent similar incidents in future. The action plans included the development of a "Nursing Home Transfer" form that include an area to note if the patient is on a ventilator and "if yes current vent settings or O2 requirements", use of this form was to be implemented within 2 weeks of the RCA completion. Other actions plans included: training Emergency Department staff on use of the form and auditing 10 cases per week to evaluate effectiveness of implementing the form.

The facility also identified that the Medical Executive Committee (MEC) was to address physicians working or receiving report on patients sent to the Emergency Department, need to contact the designated ED physician and provide "appropriate information to facilitate safe care and admission information". This was to be addressed at the MEC meeting on 11/12/13.

Review of facility provided documentation revealed the above facility identified actions had not been effectively implemented, monitored, or evaluated by the facility.

Cross refer to A0286.

Due to the facility's failure to ensure that the proposed quality improvement action plans related to an adverse event were appropriately implemented and monitored, there remains a risk for a similar adverse event to occur, compromising the safety of patients in the facility.

The above findings were confirmed in an interview on 12/04/13 with staff members #1 and 4.

Based on a review of records, documentation, and interview, it was determined that the facility failed to ensure that the director of nursing was responsible for the operation of the service, as evidence by not following facility based policy and procedures for documentation.

Findings were:

Facility policy entitled "Notification of Physician" stated in part, "7. The physician should be notified of any of the following utilizing SBAR communication:


a. Immediately upon death of a patient ...

e. Change in patient condition to include but not limited to those things listed below:
(1) signs of respiratory distress or change in character of respirations, dyspnea, retractions, decreased or uneven excursions of the chest ...

9. Documentation should reflect:
a. what prompted the physician notification,
b. the time of notification,
c. time of physician response
d. brief synopsis of what was told to the physician, the physicians' response."

A review of the medical record for patient # 1 revealed documentation of changes in respiratory status. Respiratory documentation at on 09/27/13 at 2200 indicated gasping and agonal breathing. On 09/27/13 at 2100 a physical assessment by the nurse indicated the patient was having "gasping" and "agonal" breathing. On 09/27/13 at 2300 it was documented the "pt. unable to give information". There was no documentation of the staff notifying the physician of this change in the patient's condition per facility based policy. Per facility based policy, documentation of physician notification should include: what prompted the notification, time of notification, time of physician response, synopsis of information provided to the physician, and physician response.

In an interview on 12/04/13, staff member # 5 stated she found the patient unresponsive in the morning on 09/28/13, "The ER nurse told me in report the he was a DNR. I came in, we had noted he was DNR. We did a sternal rub and he didn't wake up. Secretary came and said he was flat lined. The charge nurse called the doctor." The patient expired at 03:15 AM on 09/28/13. There was no documented description of the events leading the patient's pronouncement of death in the medical record. In an interview on 12/04/13, staff member # 5 was asked if they documented the attempts to rouse the patient with sternal rub and subsequent death. She replied, "Honestly, I probably didn't." There was also no documented notification of the physician of the patient's death, per policy.

Facility based policy entitled, "Pressure Ulcer" stated in part, "1. If the patient is admitted with or develops a pressure ulcer(s), assessment care, documentation and physician notification will be completed in a timely manner."

Facility based policy entitled, "Skin Care Protocols" stated in part, "6. If actual breakdown is present: The physician should be notified. Stage I and II ulcers should be assessed by the primary TPCN, Wound Ace, and/or Charge Nurse. Care should be initiated per Skin Integrity Care Plan."

A review of the medical record for Patient # 2 revealed photo documentation on 09/16/13 at 05:09 of a pressure ulcer on the patient's coccyx/sacrum that measured 8.45 cm X 8.27 cm. There was no documented notification of the physician about the pressure ulcer that was photo documented. Review of the electronic medical record by this surveyor and a nurse familiar with the system (Staff member #9) revealed no Skin Integrity Plan in place for Patient # 2, per facility policy.

The above findings were confirmed in an interview on 12/04/13 with staff members # 2, 4, and 9.